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Health Insurance Reimb & Billing > Chapter 7 > Flashcards

Chapter 7 Flashcards

1
Q

care plan oversight services

A

cover the provider’s time supervising a complex and multidisciplinary care treatment program for a specific patient who is under the care of a home health agency, hospice, or nursing facility.

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2
Q

case management services

A

process by which an attending physician coordinates and supervises care provided to a patient by other providers.

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3
Q

Category I codes

A

procedures/services identified by a five-digit CPT code and descriptor nomenclature; these codes are traditionally associated with CPT and organized within six sections.

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4
Q

Category II codes

A

optional evidence-based performance measurement tracking codes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 1234A); these codes will be located after the Medicine section; their use is optional.

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5
Q

Category III codes

A

temporary codes for data collection purposes that are assigned an alphanumeric identifier with a letter in the last field (e.g., 0075T)

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6
Q

comprehensive assessment

A

must include an assessment of the patient’s functional capacity, identification of potential problems, and a nursing plan to enhance, or at least maintain, the patient’s physical and psychosocial functions.

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7
Q

concurrent care

A

provision of similar services, such as hospital inpatient visits, to the same patient by more than one provider on the same day.

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8
Q

Consultation

A

examination of a patient by a health care provider, usually a specialist, for the purpose of advising the referring or attending physician in the evaluation and/or management of a specific problem with a known diagnosis.

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9
Q

contributory components

A

include counseling, coordination of care, nature of presenting problem, and time.

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10
Q

coordination of care

A

provider makes arrangements with other providers or agencies for services to be provided to a patient.

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11
Q

Counseling

A

discussion with a patient and/or family concerning one or more of the following areas: diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of management (treatment) options; instructions for management (treatment) and/or follow-up; importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education.

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12
Q

CPT Coding Conventions

boldface type

A

highlights main terms in the CPT index and categories, subcategories, headings, and code numbers in the CPT manual.

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13
Q

cross-reference (see)

A

directs coders to a different CPT index entry because no codes are found under the original entry.

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14
Q

descriptive qualifier

A

terms that clarify assignment of a CPT code.

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15
Q

Guidelines

A

define terms and explain the assignment of codes for procedures and services located in a particular section.

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16
Q

inferred words

A

used to save space in the CPT index when referencing subterms.

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17
Q

instructional notes

A

appear throughout CPT sections to clarify the assignment of codes.

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18
Q

italicized type

A

used for the cross-reference term, See, in the CPT index.

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19
Q

CPT Symbols

A
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20
Q

critical care services

A

reported when a provider directly delivers medical care for a critically ill or critically injured patient.

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21
Q

direct patient contact

A

refers to face-to-face patient contact (outpatient or inpatient).

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22
Q

emergency department services

A

services provided in an organized, hospital-based facility, which is open on a 24-hour basis, for the purpose of “providing unscheduled episodic services to patients requiring immediate medical attention.”

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23
Q

established patient

A

one who has received professional services from the provider, or from another provider of the same specialty who belongs to the same group practice, within the past three years.

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24
Q

Evaluation and Management Documentation Guidelines

A

federal (CMS) guidelines that explain how E/M codes are assigned according to elements associated with comprehensive multisystem and single-system examinations.

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25
Q

Evaluation and Management (E/M) section

A

located at the beginning of CPT because these codes describe services (e.g., office visits) that are most frequently provided by physicians and other health care practitioners (e.g., nurse practitioner, physician assistant).

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26
Q

extent of examination (CPT)

A

includes comprehensive, detailed, expanded problem focused, and problem focused levels, based on physician documentation.

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27
Q

comprehensive examination

A

general multisystem examination or a complete examination of a single organ system.

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28
Q

detailed examination

A

extended examination of the affected body area(s) and other symptomatic or related organ system(s).

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29
Q

expanded problem focused examination

A

limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

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30
Q

problem focused examination

A

limited examination of the affected body area or organ system.

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31
Q

extent of history (CPT)

A

includes comprehensive, detailed, expanded problem focused, and problem focused levels, based on physician documentation.

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32
Q

comprehensive history

A

chief complaint, extended history of present illness, review of systems directly related to the problem(s) identified in the history of the present illness, plus a review of all additional body systems and complete past/family/social history.

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33
Q

detailed history

A

chief complaint, extended history of present illness, problem-pertinent system review extended to include a limited number of additional systems, pertinent past/family/social history directly related to patient’s problem.

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34
Q

expanded problem focused history

A

chief complaint, brief history of present illness, problem-pertinent system review

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35
Q

problem focused history

A

chief complaint, brief history of present illness or problem.

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36
Q

face-to-face time

A

amount of time the office or outpatient care provider spends with the patient and/or family.

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37
Q

global period

A

includes all services related to a procedure during a period of time (e.g., 10 days, 30 days, 90 days, depending on payer guidelines)

38
Q

global surgery

A

also called package concept or surgical package; includes the procedure, local infiltration, metacarpal/digital block or topical anesthesia when used, and normal, uncomplicated follow-up care.

39
Q

history

A

interview of the patient that includes the following components: history of the present illness (HPI) (including the patient’s chief complaint), a review of systems (ROS), and a past/family/social history (PFSH).

40
Q

home services

A

health care services provided in a private residence.

41
Q

hospital discharge services

A

includes the final examination of the patient; discussion of the hospital stay with the patient and/or caregiver; instructions for continuing care provided to the patient and/or caregiver; and preparation of discharge records, prescriptions, and referral forms.

42
Q

indented code

A

CPT code that is indented below a stand-alone code, requiring the coder to refer back to the common portion of the code description that is located before the semicolon.

43
Q

initial hospital care

A

covers the first inpatient encounter the admitting/attending physician has with the patient for each admission.

44
Q

key components

A

extent of history, extent of examination, and complexity of medical decision making.

45
Q

level of service

A

reflects the amount of work involved in providing health care to patients.

46
Q

medical decision making

A

refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the number of diagnoses or management options, amount and/or complexity of data to be reviewed, and risk of complications and/or morbidity or mortality.

47
Q

moderate (conscious) sedation

A

administration of moderate sedation or analgesia, which results in a drug-induced depression of consciousness.

48
Q

modifier

A

provide additional information about a procedure or service (e.g., left-sided procedure).

49
Q

monitored anesthesia care (MAC)

A

provision of local or regional anesthetic services with certain conscious-altering drugs when provided by a physician, anesthesiologist, or medically directed CRNA; monitored anesthesia care involves sufficiently monitoring the patient to anticipate the potential need for administration of general anesthesia, and it requires continuous evaluation of vital physiologic functions as well as recognition and treatment of adverse changes.

50
Q

multiple surgical procedures

A

two or more surgeries performed during the same operative session

51
Q

nature of the presenting problem

A

defined by CPT as a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.

52
Q

new patient

A

one who has not received any professional services from the provider, or from another provider of the same specialty who belongs to the same group practice, within the past three years.

53
Q

newborn care

A

covers examinations of normal or high-risk neonates in the hospital or other locations, subsequent newborn care in a hospital, and resuscitation of high-risk babies.

54
Q

nursing facility services

A

performed at the following sites: skilled nursing facilities (SNFs), intermediate care facilities (ICFs), and long-term care facilities (LTCFs).

55
Q

observation or inpatient care services

A

CPT codes used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service.

56
Q

observation services

A

furnished in a hospital out-patient setting to determine whether further treatment or inpatient admission is needed; when a patient is placed under observation, the patient is categorized as an outpatient; if the duration of observation care is expected to be 24 hours or more, the physician must order an inpatient admission (and the date the physician orders the inpatient stay is the date of inpatient admission).

57
Q

organ- or disease-oriented panel

A

furnished in a hospital out-patient setting to determine whether further treatment or inpatient admission is needed; when a patient is placed under observation, the patient is categorized as an outpatient; if the duration of observation care is expected to be 24 hours or more, the physician must order an inpatient admission (and the date the physician orders the inpatient stay is the date of inpatient admission).

58
Q

multiple surgical procedures

A

two or more surgeries performed during the same operative session.

59
Q

nature of the presenting problem

A

defined by CPT as a disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.

60
Q

new patient

A

one who has not received any professional services from the provider, or from another provider of the same specialty who belongs to the same group practice, within the past three years.

61
Q

newborn care

A

covers examinations of normal or high-risk neonates in the hospital or other locations, subsequent newborn care in a hospital, and resuscitation of high-risk babies.

62
Q

nursing facility services

A

performed at the following sites: skilled nursing facilities (SNFs), intermediate care facilities (ICFs), and long-term care facilities (LTCFs)

63
Q

observation or inpatient care services

A

CPT codes used to report observation or inpatient hospital care services provided to patients admitted and discharged on the same date of service.

64
Q

observation services

A

furnished in a hospital out-patient setting to determine whether further treatment or inpatient admission is needed; when a patient is placed under observation, the patient is categorized as an outpatient; if the duration of observation care is expected to be 24 hours or more, the physician must order an inpatient admission (and the date the physician orders the inpatient stay is the date of inpatient admission).

65
Q

organ- or disease-oriented panel

A

series of blood chemistry studies routinely ordered by providers at the same time to investigate a specific organ (e.g., liver panel) or disease (e.g., thyroid panel).

66
Q

partial hospitalization

A

short-term, intensive treatment program where individuals who are experiencing an acute episode of an illness (e.g., geriatric, psychiatric, or rehabilitative) can receive medically supervised treatment during a significant number of daytime or nighttime hours; this type of program is an alternative to 24-hour inpatient hospitalization and allows the patients to maintain their everyday lives without the disruption associated with an inpatient hospital stay.

67
Q

physical examination

A

assessment of the patient’s body areas (e.g., extremities) and organ systems (e.g., cardiovascular).

68
Q

physical status modifier

A

indicates the patient’s condition at the time anesthesia was administered.

69
Q

place of service (POS)

A

the physical location where health care is provided to patients (e.g., office or other outpatient settings, hospitals, nursing facilities, home health care, or emergency departments); the two-digit location code is required by Medicare.

70
Q

preoperative clearance

A

occurs when a surgeon requests that a specialist or other physician (e.g., general practice) examine a patient and give an opinion as to whether that patient can withstand the expected risks of a specific surgery.

71
Q

preventive medicine services

A

routine examinations or risk management counseling for children and adults exhibiting no overt signs or symptoms of a disorder while presenting to the medical office for a preventive medical physical; also called “wellness visits.”

72
Q

professional component

A

supervision of procedure, interpretation, and writing of the report.

73
Q

prolonged services

A

assigned in addition to other E/M services when treatment exceeds by 30 minutes or more the time included in the CPT description of the service.

74
Q

qualifying circumstances

A

CPT Medicine Section codes reported in addition to Anesthesia Section codes when situations or circumstances make anesthesia administration more difficult (e.g., patient of extreme age, such as under one year or over 70).

75
Q

radiologic views

A

studies taken from different angles.

76
Q

referral

A

a patient who reports that another provider referred him or her.

77
Q

resequenced code

A

CPT codes that appear out of numerical order and are preceded by the # symbol (so as to provide direction to the out-of-sequence code).

78
Q

separate procedure

A

follows a CPT code description to identify procedures that are an integral part of another procedure or service.

79
Q

special report

A

must accompany the claim when a CPT unlisted procedure or service code is reported to describe the nature, extent, and need for the procedure or service.

80
Q

stand-alone code

A

CPT code that includes a complete description of the procedure or service.

81
Q

standby services

A

cover providers who spend prolonged periods of time without direct patient contact, until provider’s services are required.

82
Q

subsequent hospital care

A

includes review of patient’s chart for changes in the patient’s condition, the results of diagnostic studies, and/or reassessment of the patient’s condition since the last assessment performed by the physician.

83
Q

surgical package

A

see global surgery.

84
Q

technical component

A

use of equipment and supplies for services performed.

85
Q

Telemedicine

A

use of equipment and supplies for services performed.

86
Q

Telemedicine

A

provision of remote medical care an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site; an alternative to in person face-to-face encounters.

87
Q

transfer of care

A

occurs when a physician who is managing some or all of a patient’s problems releases the patient to the care of another physician who is not providing consultative services.

88
Q

type of service (TOS)

A

refers to the kind of health care services provided to patients; a code required by Medicare to denote anesthesia services

89
Q

unit/floor time

A

amount of time the provider spends at the patient’s bedside and managing the patient’s care on the unit or floor (e.g., writing orders for diagnostic tests or reviewing test results).

90
Q

unlisted procedure

A

also called unlisted service; assigned when the provider performs a procedure or service for which there is no CPT code.

91
Q

unlisted service

A

see unlisted procedure.

92
Q

without direct patient contact

A

includes non-face-to-face time spent by the provider on an outpatient or inpatient basis and occurring before and/or after direct patient care.

Health Insurance Reimb & Billing (7 decks)

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